Cooperative Boating Accident Investigation Presented to NASBLA September 30, 2009, Corpus Christi, Texas By Rob Henry
Presentation Overview Brief description of NTSB NTSB marine accident investigation NTSB safety recommendations April 12th Jacksonville, Florida boating accident Opportunities and challenges
42 Years Ago - 1967-2009 Created in 1967 by the Congress with the authority to investigate aviation, marine, rail, highway, pipeline, and hazmat transportation accidents. In 1974,Congress made the NTSB completely independent of the DOT.
Mission of the NTSB The NTSB is charged with Determining the probable cause(s) of transportation accidents, and Making recommendations to prevent their recurrence.
The Safety Board Members The Safety Board consists of five Members, appointed by the President, with the advice and consent of the Senate. Members serve 5-year staggered terms.
Authority to Investigate Marine Accidents MayInvestigate Any Major Marine Accident Involving a Foreign Vessel Which Occurs in U. S. Waters May Investigate Any Major Marine Accident Involving a U.S. Ship Anywhere in the World Shall Investigate Any Collision Between a Public and a Non-Public Vessel May Investigate Other Marine Accidents of a Recurring Nature
Major Marine Accident Definition Six or More Lives Lost Total Loss of a Self-Propelled Vessel of 100 Gross Tons or more $500,000 or more in Property Damage Serious Threat to Life, Property, or the Environment From the Release of Hazardous Materials
There Are Many Different Types of Marine Accidents The Office of Marine Safety Investigates. . .
Collisions
Groundings
Fires
Explosions
And Last,
But Not Least . . .
We Also Investigate
Sinkings
There are Many Different Types of Vessels Involved in Marine Accidents, Including . . .
Foreign Passenger Ships
Domestic Passenger Vessels
Commercial Fishing Vessels
Offshore Service Vessels
Offshore Supply
Mobil Offshore Drilling Units
Tankships
Tugboats
Towboats
Barges
Containerships
And Last, But Not Least,
Recreational Boats
Number of Accidents In An Average Year, About 6000 Commercial Vessel Accidents Reportable To The Coast Guard About 30-40 Of These Accidents Meet At Least One Criteria For Major Marine Accident NTSB Investigates Approximately 6-8 Major Marine Accidents Each Year
Independent Investigation Under NTSB Rules Accident Has Significant Safety Issues Accident Has High Loss of Life or Major Pollution Accident Has Wide Public Interest, or Accident Involves Public Vessel or Major Coast Guard Function
Under NTSB Rules Launch “GO TEAM” On 24-Hour Call 365 Days A Year Enroute In 2 Hours of Notification
Typical Go Team Investigator-In-Charge Marine Engineering Group Chairman Human Performance Group Chairman Survival Factors Group Chairman Other Group Chairmen, As Necessary Fire Science Metallurgy Hazardous Materials
Member Launch Safety Board Member May Launch With Team, Depending Upon Seriousness Typically will include a public affairs officer and a family assistance specialist.
Investigation to Report On scene investigation usually takes one to two weeks Report development will take a year for a complex major marine investigation
Board Meeting The Board Members conduct a public meeting to discuss and approve a final report on the accident. The final report includes conclusions, a statement of probable cause, and recommendations.
Safety Recommendations Safety recommendations are the Board’s most important product They are developed to remedy system, hardware, operational or policy failures identified during investigations
Safety Recommendations Recommendations are issued to DOT and its modal administrations, DHS (US Coast Guard), manufacturers, transportation operators, trade associations, labor unions and state and local governments
Major Accomplishments Improved Fire Protection on Cruise Ships Sprinkler Systems Smoke Detectors Improved Lifesaving Equipment on Commercial Fishing Vessels Life rafts Survival Suits EPIRBs Improved Navigation Safety Bridge Resource Management Training Standardization of Integrated Bridge Navigation Systems
“Most Wanted” List Safety recommendation issuearea selected by the Board for intensive follow-up because it: Will impact or enhance safety on the national level Has high public visibility and interest Can be implemented in a reasonable period of time; and Is an area that would benefit from this special form of encouragement
NTSB Safety Initiatives 1993 Recreational Boating Safety Study 1998 PWC Safety Study 2006 public forum on life jackets 2006 sole state waters seminar
Prior NTSB Boating Accidents July 3, 1999, Bayport, MN - Advantage & Bayliner - 5 of 5 fatal December 29, 1997, Charleston, SC – Morning Dew - 4 of 4 fatal August 21, 1994, Juneau, AK – Questar - 1of 2 fatal
Allision of the Unnamed Recreational Vessel (Crownline 22) with the towing vessel Little Man II, near Palm Valley, Florida April 12, 2009
Arial photos
Arial photos
M/V Little Man II - damage
Crownline 22 damage
Consequences of Accident 14 Passengers – none ejected 5 fatalities 9 seriously injured 3 medevaced to local hospitals No one walked away from the accident unscathed Unique opportunity to conduct a Federal-State Cooperative boating accident investigation
Launch Early decision between NTSB and USCG on Federal primacy Duty Board Member to launch Go Team Notification of launch to Florida FWC Lead investigator contact Public affairs contact Team arrival Jax and press conference
Arrival On Scene Set Up Command Post IIC Holds Organizational Meeting Designates Parties to the Investigation Explains Ground Rules Forms Investigative Groups Groups Disperse to Conduct Investigation Progress Meetings Every Evening
Party Designation Organizations are Named as Parties Because they Have Special Knowledge or Resources that the Board Needs to Complete the Investigation. Party Representatives Can Not Be Lawyers or Insurers & Must Have Technical Qualifications
Parties to investigation Florida FWC Region supervisor 5 investigators, 1 PAO U.S. Coast Guard Senior investigating officer (LT) Inspections division chief (LT)
Causal Issues – proximate cause Human factors Deceased sitting “operator” Lacked training and experience, inattention, view obstructions, line of sight, distractions Surviving standing “operator” Intoxication, inattention, distractions Owner of record Responsibility for oversight of vessel operation, intoxication
NTSB Authority Issues Subpoenas Take Testimony Under Oath May Enter Any Property Where Accident Has Occurred Copy Pertinent Files and Documents Order Autopsy of Accident Victims Test any component of the wreckage
NTSB Resources Materials laboratory Transportation disaster assistance/ family assistance Medical evaluation of autopsies and tox tests. MD on staff Commercial vessel A/I experience Weather data retrieval and analysis Data recorder recovery and analysis Human factors specialist Tox laboratory
State Capability and Resources Accident reconstruction and documentation expertise Local knowledge Site security Logistical support
Challenges to Cooperation Early communications and coordination Non-criminal process Lawyers/due process Overlapping investigation needs Interviews Data and evidence collection Access to accident site Limited opportunity to investigate recreational boating accidents
Challenges Public dissemination of information Conflicting A/I protocols Safety vs. law enforcement Rights of interviewees Warnings Immunity Self-incrimination Representation Collection of evidence (rules of, chain of custody) Transparency of NTSB investigation
Conclusion Why is mutual cooperation important to each of us?
Judicial Process and NTSB Board employees may testify once (through deposition or interrogatories) for all civil litigations (49 CFR § 835.5) NTSB makes available unique factual information not otherwise available NTSB Board Reports may not be used or admitted into evidence in any action for damages arising from an accident (49 CFR § 835.3) Interaction with United States Attorneys is rare and limited General Counsel determines if staff may testify in criminal matter (49 CFR § 835.10)
NTSB and the Coast Guard
Joint Regulations (49 CFR Part 850)
NTSB – USCG Memorandum of Understanding, signed December 19, 2008
Coast Guard a party to NTSB-led investigations
NTSB
NTSB Has Three Options:
Request the Coast Guard to Investigate On Behalf of the Safety Board With No NTSB Participation, or
Conduct a Joint Investigation With the Coast Guard Under Coast Guard Rules, or
Conduct an Independent Investigation Under NTSB Rule.
Investigating Marine Accidents Entire Marine Investigative Staff Works Out of Washington, D.C. Headquarters Current Marine Technical Staff - Persons Master Mariners Licensed Marine Engineers Naval Architects Human Performance Survival Factors
In 2006, following the Ethan Allen accident, NTSB h more
In 2006, following the Ethan Allen accident, NTSB held a training seminar on NTSB marine accident investigations of sole-state passenger vessel accidents which provided the initiative to revise the Model Act for charter Vessel Safety. Recreational boating accident investigations jointly worked between a state and NTSB are a much different process and sharing the lessons learned from the April 12, 2009 Jacksonville boating accident jointly investigated by Florida FWC and NTSB will benefit both the NTSB and NASBLA membership in future cooperative investigations and recognition of each others roles and responsibilities in boating safety. less
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